Basic Information
| Provider Information | |||||||||
| NPI: | 1003383530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODIN | ||||||||
| FirstName: | ROSEANNE | ||||||||
| MiddleName: | ELYSE | ||||||||
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| Credential: | M.A., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2517 ELLA LEE LN | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770196312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133021911 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4620 BELLAIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | BELLAIRE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774014231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136653888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2018 | ||||||||
| LastUpdateDate: | 11/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 106752 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 106752 | 01 | TX | SPEECH PATHOLOGIST | OTHER |